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Research has revealed that the number of annual psychiatrist reviews being carried out in patients prescribed antipsychotics has decreased, while the number of antipsychotics being prescribed for sole management in general practice has increased.
The serial cross-sectional study, published in the British Journal of General Practice on 26 November 2024, revealed that the prevalence of adults aged over 18 years in Wales who have been prescribed with long-term antipsychotics between 2011 and 2020 increased from 1.1% to 1.5%, while the proportion receiving annual psychiatrist reviews has declined from 59.6% to 52.0%.
The study results also highlighted that the proportion of patients on the Quality and Outcomes Framework Serious Mental Illness (QOF SMI) register who were prescribed antipsychotics has declined during this time, from 50.0% to 43.6%, “meaning fewer patients would receive recall for cardiometabolic monitoring”.
As a result, the researchers from the University of Liverpool said that, accounting for “the usual cautions around extrapolation”, approximately 360,000 to 390,000 patients in the UK “may be being prescribed antipsychotics long term without regular psychiatric review”.
“Changes in policy are needed to prevent patients being ‘trapped’ on antipsychotics long term without psychiatrist review and ensure adequate cardiometabolic monitoring if the premature mortality experienced by patients with psychiatric illnesses is to be addressed,” they added.
Antipsychotics are licensed in the UK for the management of psychotic illnesses, such as schizophrenia and bipolar disorder — conditions for which GPs receive funding to undertake annual physical health checks.
Lead author Alan Woodall, clinical lead GP in integrated health and research at Powys Teaching Health Board, said: “The problem is that the pressures on psychiatric services are so severe that psychiatrists are under pressure to discharge all patients but those with serious mental illness, bipolar or schizophrenia on an antipsychotic.
“Even if the [National Institute for Health and Care Excellence] guidance will say only short-term use… because there’s no psychology provision, they get discharged because they can’t sit on the waiting list for two years to have psychology [input].”
“So, they start them on an antipsychotic and discharge them back to the GP. And we now find that nearly half of all patients taking long-term antipsychotics are running under GP care,” he said.
“The thing that we’ve got to do at the moment is signposting. One of the good things about pharmacists, is that they know their patients really well. They can challenge and say, ‘have you had your blood pressure checked recently, as these drugs can affect it’.”
Commenting on the study, Steve Bazire, honorary professor at the University of East Anglia School of Pharmacy, said: “This careful and comprehensive study of antipsychotic prescribing in Wales from 2011 to 2020 has helped confirm what many of us feared, but with some good news.
“The proportion of adults taking antipsychotics long term increased from 1% to 1.5%, exclusively in the 18–64 [years] age group. [But] there was a decrease in use in people of 65 [years] or over from 1.5% to 1.4%, including a welcome reduced use in dementia, falling from 16.7% to 12.9%.
“The biggest concern expressed is that over 50% people prescribed long-term antipsychotics are not on the QOF SMI register and so do not get an automatic recall for annual cardiovascular and physical health review, nor are funded for this,” he added.
Orla Macdonald, lead research pharmacist at Oxford Health NHS Foundation Trust and council member of the College of Mental Health Pharmacy, said: “The point about regular psychiatrist review is an interesting one. Yes, we would expect most antipsychotics to be started by psychiatrists or under their guidance, but many patients recover well with treatment and can be safely discharged back to GP care.
“Funding and support for physical health monitoring should remain within primary care and, in my view, it would be wrong to suggest that a patient needs to have an annual review with a psychiatrist, just to ensure that their physical health monitoring is done,” she said.
“However, authors have made a very valid point about how pharmacists can help here. Those pharmacists who are either based in or supporting GP surgeries can certainly help with this burden of identifying and implementing the required monitoring for patients on antipsychotics.”
